Durable Medical Equipment, Prosthetics, Orthotics, Supplies

Final Rule Confirms Certain Items Will Require Prior Authorization

In the closing days of 2015, CMS announced a final rule(www.gpo.gov) that states the agency soon will increase mandatory prior authorizations for certain durable medical equipment, prosthetics, orthotics and supplies (DMEPOS).

The rule goes into effect on Feb. 29 and signifies another move in CMS' stepped-up efforts to reduce fraud and abuse associated with some DMEPOS items.

This final rule allows for the establishment of a prior authorization process for items that frequently are subject to unnecessary utilization (defined as not compliant with one or more of Medicare's coverage, coding and payment rules) and for the creation of a master list of 135 DMEPOS items potentially subject to prior authorization.

According to a CMS fact sheet,(www.cms.gov) master list items will show an average purchase price of $1,000 or more or an average rental fee of $100 or more. These items also will have been featured as problematic in one of three reports generated by the federal government.

Story Highlights

A final rule announced by CMS late in December states that the agency soon will increase mandatory prior authorizations for certain durable medical equipment, prosthetics, orthotics and supplies (DMEPOS).

The rule goes into effect on Feb. 29 and signifies another move in CMS' stepped-up efforts to reduce fraud and abuse associated with some DMEPOS items.

The final rule allows for the establishment of a prior authorization process and for the creation of a master list of 135 DMEPOS items potentially subject to prior authorization.

Selected DMEPOS items will remain on the list for 10 years but can be removed sooner if the purchase amount drops below the payment threshold. After 10 years, DMEPOS items can remain on the list -- or be added back to the list -- "if a subsequent report identifies the item as frequently subject to unnecessary utilization."

The "required prior authorization list" -- as established by CMS -- will be published in the Federal Register 60 days before implementation.

According to the final rule, prior authorization will be required for DMEPOS items on this list. As explained in a Jan. 5 post in Family Practice Management's Getting Paid Blog, suppliers most often will start the authorization process by getting the proper information to CMS. However, noted the blog, "prescribing or ordering physicians should not be surprised if the supplier asks their office for assistance."

Importantly, CMS requires that prior authorization evidence must be in hand before the patient receives the DMEPOS item. Physicians also should note these additional details:

CMS or its contractors will review each prior authorization request and provide a provisional affirmation or nonaffirmation decision.

A claim submitted with a provisional affirmation decision will be paid so long as all other requirements are met.

A claim submitted with a nonaffirmation decision or without a decision will be denied.

Unlimited resubmissions of prior authorization requests are allowed.

An initial prior authorization determination will be made within 10 business days; resubmitted requests will be processed within 20 days.

Expedited review will be available if the normal wait time could seriously jeopardize the life or health of a patient.

Unfortunately, despite the AAFP's ongoing efforts to help cut bureaucratic red tape for family physicians, the new DMEPOS rule may add a layer of administrative work to already busy medical offices.

In fact, the AAFP expressed that very concern when the proposed rule was published for comment in May 2014. In a July 2014 letter(3 page PDF) to CMS, (then) AAFP Board Chair Jeff Cain, M.D., of Denver, urged CMS to "accurately account for the burden on physicians" before adopting a final rule.

He noted the AAFP's support for efforts to prevent fraud, waste and abuse in the Medicare system, and added that family physicians and their patients would most benefit from a prior authorization process that would help "determine appropriate care" based on a patient's existing health insurance coverage.